Geriatric Hip Fracture
Program
Christina McQuiston M.B.Ch.B.
Mission Hospitals, Asheville, NC
The Problem
• 300,000 Americans experience a hip
fracture annually
• In 2005 fragility fractures cost around $19
billion
• By 2025 it is predicted that these costs will
rise to around $25billion.
• Around 24% of such patients over 50 will
die in the year following a fracture
Hip Fracture Repair per 1,000 Medicare Enrollees
(2003)
National Average
7.53
1. Oklahoma
9.06
2. Tennessee
8.87
3. Georgia
8.78
3. North Carolina
8.78
11. South Carolina
8.28
23. Florida
7.46
Source: Dartmouth Atlas 2003
Hip Fracture Repairs NC Hospitals
2005
Mission Hospitals
Duke University Medical Center
New Hanover Regional
Moses Cone
Forsyth Memorial
Presbyterian
Carolinas Medical Center
Pitt County
The NC Baptist Hospitals
First Health Moore Regional
WakeMed
Gaston Memorial
UNC Hospitals
Northeast Medical Center
Rex Healthcare
Cape Fear Valley
High Point Regional
Rowan Regional
Alamance Regional
Cleveland Regional
Pardee Hospital
Medicare volumes
COUNT
414
389
302
283
243
215
197
197
182
167
165
161
161
160
157
141
140
120
116
106
102
2006
Mission Hospitals
Duke University Medical Center
Moses Cone
Forsyth Memorial
New Hanover
Carolinas Medical Center
Presbyterian
WakeMed
The NC Baptist Hospitals
Pitt County Memorial
First Health Moore Regionsl
Gaston Memorial
Rex Healthcare
UNC Hospitals
Cape Fear Valley
Northeast Medical Center
High Point Regional
Rowan Regional
Durham Regional
Frye Regional
Alamance
Pardee Hospital
COUNT
402
342
309
284
278
238
237
203
187
186
185
178
173
153
141
141
135
121
118
117
116
112
Mission Hospitals
All payers
2006
2007
Total number
586
563
Total number
over age 64
492
454
ALOS all pts
5.8 days
6.36 days
Mission
Hospitals:
Net
income
per Case
Patients with CC and MCC
$0
($200)
FY 0 6
FY 0 7
FY 0 8 Q 1
($400)
($600)
($800)
($1,000)
($1,200)
($1,400)
($1,600)
($1,800)
($2,000)
Patients without CC or MCC
$400
$200
$0
($200)
($400)
($600)
($800)
($1,000)
FY 0 6
FY 0 7
FY 0 8 Q 1
Environmental Survey
• Reviewed literature on co-management models. Shows
decreased LOS and readmissions.
• Reviewed anesthesia literature. Less delirium with
spinal anesthesia.
• Reviewed and incorporated CHEST guidelines for VTE
prophylaxis.
• Reviewed orthopedic literature regarding post hip
fracture weight bearing status.
• Reviewed current recommendations for osteoporosis
treatment.
• Site visit to Highland hospital in Rochester NY to review
their process. (data published this summer)
Plan Outline
All patients with fragility hip
fractures(>65yr)
Orthopedist remains attending physician.
All patients co-managed by hospitalist.
Elder specific pre and post op order sets.
Consistent early weight bearing.
Chest guidelines for VTE prophylaxis.
Incorporate osteoporosis treatment.
Current Work
• Improve collaboration among ER
physicians, orthopedists, hospitalists and
anesthesiologists.
• Develop a protocol driven medical comanagement process.
• Streamline throughput from admission to
discharge.
• Create elder specific computerized power
plans.
Medical Co-Management
• Standardize the initial medical consult
with attention to geriatric syndromes.
• Accurately document medical comorbidities.
• Stratify risk.
• Coordinate additional consults.
• Actively manage the discharge process.
Everyone Wins
• Door to OR in <24 hrs.
• Reduce length of stay.(4 day goal)
• Reduce costs.
• Reduce complications.
• Reduce hospital acquired delirium.
• Reduce readmissions.
• Increase patient and family satisfaction.
Door to OR data
ED to OR
Hours
79% fall under 24 hours
n=101
80
70
60
50
40
30
20
10
0
0
20
40
60
80
100
Volume
ED to OR
25
18.81%
Volume
20
15
10.89%
10
5
20.79%
19.80%
18.81%
6.93%
3.96%
0
≤4
4-8
8-12
12-16
Hours
16-20
20-24
> 24
Readmission-Reasons
46 Patients
Anemia
1
Aspiration Pneumonia
1
Atrial Fibrillation
3
C Diff Colitis
2
CHF
2
Cholelithiasis
1
Dehydration
3
Dysphagia
1
Fever
1
Gangrene non-operative leg
1
GI bleed
1
Hip dislocation
7
HTN
1
Ileus
1
Lag screw cut femoral head
1
Nausea
2
New fracture
9
Non-union
1
Pain
1
Pancreatitis
1
Pneumonia
6
Septic Shock
2
Thrombus
1
UTI
3
Wound Erythema
2
Wound Infection
6
Readmissions
Readmissions – Timing
46 Patients
Returned within 7 days
16
Returned between 8-14 days
12
Returned between 15-21 days
8
Returned between 22-31 days
10
APR
DRG
Cases
APR
Readmission
Rate
Expected
APR
Readmission
Rate
Expected
APR
Readmission
Rate Index
308
418
7.56%
10.45%
0.76
309
51
9.80%
10.93%
0.74
Barriers
• Hospitalists fears over “scope creep”
• Surgical outliers regarding delays from
admission to OR
• Inter-hospital transfers (we have 2 campuses)
• OR availability
• Weekend discharges to rehabilitation facilities
• Medicare part A reimbursement for SNF care
and VTE prophylaxis.( Coumadin vs
Arixtra/lovenox)
Facilitators
• Administrative advocate
• Support from orthopedic service line
leader
• Access to data collection and statistician.
• Enthusiastic and supportive nursing staff.
Time Line
• October 2008 . Turn on geriatric specific
pre and post op order sets.
• November . Formalize agreement with
hospitalists.
• January. Roll out new discharge process.
• February. Incorporate delirium
prevention and management and the
HELP program.
Year 2
• Work with SNF’s on post hip fracture care.
• Develop out patient falls prevention
program with community partners.
• Develop osteoporosis management
strategy for SNF’s.
Delirium Task Force
• Develop standardized tools for
documentation (CAM)
• Non pharmacological approaches to
prevention and management,
• Streamline medication options for
treatment.
• HELP pilot.
Long Term Goals
• To provide a best practice model for the
hospitalized older patient .
• The hospitalist as geriatrician.
• To heighten visibility of Senior Services in
my institution.
• Earn a “place at the table” for geriatrics
What I’ve Learned
• “A prophet is not without honor except in
his or her own country.”
• That and the importance of data to
administrative support.